The Impact of Baked Egg and Baked Milk Diets on IgE- and Non-IgE-Mediated Allergy

Abstract

Baked milk (BM) and baked egg (BE) diets are increasingly used in the management of milk and egg allergy, rather than avoidance. Children with tolerance versus reactivity to BM and BE may have smaller skin prick test and lower specific IgE, and BM-tolerant children have less basophil reactivity and more peripheral T regulatory cells. However, most milk- and egg-allergic children tolerate BM and BE and an individual’s reactivity is unpredictable. Non-reactivity is due to conformational changes in the allergens. Significant differences in the published advice about methods of introduction exist from graded introduction at home to a medically supervised full dose. These approaches carry different risks and may have different immunological effects. Reactivity to BM is a predictor of a severe milk allergy. Therefore, medical supervision for BM and BE introduction is prudent. The baked diet allows dietary liberation. Most, but not all, BM- and BE-tolerant children continue eating the baked foods. The prognosis of children who can eat BM and BE is favorable with likely resolution of their allergy over the next few years. Murine models of BE diets demonstrate that heated egg can impart clinical protection against anaphylaxis and cause immune changes. Most observational human studies of BM and BE diets demonstrate clinical resolution of allergy and favorable immune changes versus regular care controls. However, the one randomized controlled trial for the BE diet in BE-tolerant children did not support an immune-modifying effect of the BE diet. Another study of BE immunotherapy is expected to be completed in 2018. There is currently no evidence for prevention of allergy with the baked diets. There may be a future role for BM and BE in liberating the diets of individuals with non-IgE-mediated allergy given recent studies that a subset of these patients can consume BM without a clinical reaction.

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Conflict of Interest

Author JU has received research funding from SickKids Foundation and the Department of Pediatrics, Hospital for Sick Children, speaker honorarium from Food Allergy Canada, research support from DBV, Aimmune, and ALLEVIATE, and is the Anaphylaxis and Food Allergy Section Chair for the Canadian Society of Allergy and Clinical Immunology. Author ANW has received research funding from NIH NIAID, FARE, DBV, Nutricia, and Nestle. She serves as the DMC chair for the trial of sublingual dust mite immunotherapy for Merck, and she is a member of the Advisory Council for the Gerber Nutrition Institute and has received honoraria from Nestle, Nutricia, and Thermo Fisher Scientific. She serves as the vice chair of the Food Allergy, Dermatitis, Drug Allergy and Anaphylaxis Section of the American Academy of Allergy, Asthma and Immunology. She is the medical chair for the International FPIES Association.